Getting Started with Patient Assessment

Assessment is a basic nursing responsibility. It is essential to perform a comprehensive assessment to be able to formulate a care plan. In assessing a patient, nurses have to use their skills in observation, nursing knowledge and senses. Here are some tips on how to perform a brief but complete nursing assessment.

Review patient’s chart (if available)

Before proceeding assessment, try to read the patient’s chart to have an idea or overview of what his condition is. Knowing what the patient has helps you know what to look for and where to concentrate on. It also can provide you information that can help you trend or watch out for symptoms of complications and be able to intervene before things can get worse. It is also better to know the basic facts from the initial assessment performed upon admission than asking for it all over again.

Talk to the patient and explain the procedure

Some patient’s tend to get anxious when being observed by health professionals. Make the patient more comfortable by talking to them in a kind manner and explaining to them what you’re doing especially if physical contact is involved. Letting them know what’s going on will make them less anxious and more cooperative.

Subjective data

Assessment comprise of two types of data. Subjective, which is based on the patient’s judgment and objective, another person’s observation from the patient.

When collecting subjective data, a good start would be to ask, “How are you feeling?”. From there, you can explore further by asking more details depending on how the patient responds. Also ask for feelings of pain, and if any, ask them to rate the pain depending on which pain scale is appropriate. Remember, pain is also part of your vital signs.

Vital Signs

When taking vital signs, consider factors that can alter your findings such as recent activity, feelings of anxiety or stress. Though normal values vary per individual, books provide ranges where normal values fall in. Take note of these values and report any abnormal readings.Compare with previous values taken and from there, you can trend and predict whether the patient is getting better, worse or no changes are happening.

Physical examination

Always do it from head to toe. When performing physical assessment, remember to start from the least invasive. Use the four techniques of physical examination.

Inspection- involves visualization of the part assessed

Auscultation- use of devices such as a stethoscope to listen to sound-producing organs such as the heart and lungs

Palpation- touching and feeling for abnormalities like tenderness or tumors under the skin

Percussion- delivering slight pressure or force to listen to the pitch or sound that it produces

* When doing physical assessment to the abdomen, be careful in applying percussion and palpation because there are conditions that contraindicate physical manipulation.

There are a lot more tools out there for specific conditions but for routine, a simple but complete head-to-toe check will be enough to have a general overview of the patient’s status.